T. OKADA ET AL.491
by mouth for 48 hr, and thereafter, milk feedings were
resumed. The child has been well without trouble since
undergoing the modified Duhamel pull-through tech-
nique (Martin) at 2 years old.
3. Discussion
Loop colostomy is constructed mainly as a temporary
diversion for stools in patients with high or intermediate
anorectal malformation or Hirschsprung’s disease [7,8].
Sigmoid loop colostomy has been shown to be associated
with fewer complications compared to transverse loop
colostomy [7]. It is therefore advisable to construct a
sigmoid loop colostomy whenever possible. However,
transverse colostomy is constructed in patients with clo-
acal anomalies, such as our Case 1, based on the conside-
ration that there is insufficient distal colon for a pull-
through operation. Ileostomy is performed in patients
with total colonic or extensive Hirschsprung’s disease in
order to facilitate bodyweight gain and prevent enteroco-
litis.
Stomal prolapse is defined as protrusion of at least one
limb of the enterostomy for more than 6 cm beyond the
skin surface [3]. Prolapse has more in common with in-
testinal intussusception than it does with hernia, and, as a
corollary, is more related to point fixation and intestinal
motility than to increased intra-abdominal pressure and
abdominal wall laxity [3]. It was suspected that distal
bowel obstruction at the time of enterostomy and loose
fixation of each limb of the enteric loop were reasons for
stomal prolapse through our case experience.
Stomal prolapse is the most frequently noted compli-
cation of colostomy, occurring in 3 to 8% of all colos-
tomies, and stomas in children are more likely to pro-
lapse than those in adults [3]. Obstruction at the time of
colostomy, such as in our case of cloacal anomaly, is the
all-encompassing predisposing factor of stomal prolapse.
Chandler, et al. [3] reported that all but one of 11 pro-
lapsing colostomies in children had been done to relieve
distal obstruction. The mechanism appeared to be a dis-
proportion between the size of the fascia defect and the
smaller diameter of the bowel after decompression. Oth-
ers have put similar stress on the size of the fascial aper-
ture, and there is a continuing interest in techniques to
make the fascia fit the bowel as snugly as possible [3].
The distal limb of any colostomy or ileostomy is destined
to shrink from disuse, and therefore, is always more
likely to be a loose fit in the fascia which is, why the dis-
tal unused stoma prolapses. Many authors have stressed
suture fixation of the bowel at the fascial level to prevent
prolapse. There is a suggestion that taking the time to fix
the bowel at the fascia level may be of benefit. The loops
prolapsed 10 times more frequently, 26% vs. 2.4%, indi-
cating a very significant difference in vulnerability to
prolapse for the loop and divided types of colostomies in
adults [3]. Chandler, et al. [3] reported that 6 additional
operative procedures were performed in 4 of 69 patients
(6.0%) with stomal prolapse, and hastened colostomy
closure occurred in 14 of 69 patients (20.3%).
Patients are also sometimes very frustrated and de-
pressed because of the redundant bowel and may need
frequent hospital admission. Stomas in children beyond
12 months of age were particularly likely to prolapse [3].
Chandler, et al. [3] reported that the loops demonstrated
a greater propensity to prolapse the more proximally they
were located. However, another report found no signifi-
cant difference regarding the location of the loops, whe-
reas the prolapse rate was greater for loop than for di-
vided colostomies [8]. According to the stomal site, the
tendency for transverse colostomy to prolapse was repor-
ted previously to be 3 in 7 patients with transverse colo-
stomy, and prolapse may have been caused by the fact
that the transverse colon is relatively mobile [8]. It was
more frequent in emergency stomas created for obstruc-
tion or stoma brought through the main operative inci-
sion [6].
Several special operative techniques have been de-
scribed to decrease the risk of prolapse, such as skin bri-
dge, subcutaneous tunnel for bowel exit, purse-string su-
tures at the fascial level, and an anchoring U stitch [6].
Kransa [4] described the simple purse-string technique
for treating prolapse and intussusception of colostomy,
and the results have been excellent.
Chandramouli, et al. [1] reported that revision was
needed in 2 of 30 children (6.7%) with external intestinal
prolapse for significant obstructive stomal prolapse [3].
Four patients (6% of the prolapse group) were subjected
to an extra operative procedure because of prolapse.
Twice in one child and once in an adult, an attempt was
made to fix the prolapse in a reduced position by button
colopexy. This “spot welding” technique was unsuc-
cessful both times in the child but held the adult’s colon
in place until an appropriate time for colostomy closure
[3]. One attempt was made to fix the prolapsing bowel to
the parietal peritoneum, using open laparotomy and mul-
tiple suture points of fixation, but this prolapse recurred.
Chandramouli, et al. [1] reported that 2 prolapses were
treated by advancement and amputation of the prolapsing
segments, with reconstruction of the colostomy in the
same location but separating the 2 limbs by a fascial
bridge [3]. Al-Salem, et al. [7] reported that stomal revi-
sion was required because of frequent prolapse in 2 of 14
children who suffered prolapse. The revision rate for
colostomy prolapse is lower, but when required, usually
in a loop enterostomy such as in our cases, the loop is cut
and converted to a divided type [1]. The stoma should
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